<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Order_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-order_id" data-rule="required" data-source="order/index" class="form-control selectpage" name="row[order_id]" type="text" value="{$row.order_id|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Device_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-device_name" class="form-control" name="row[device_name]" type="text" value="{$row.device_name|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Device_model')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-device_model" class="form-control" name="row[device_model]" type="text" value="{$row.device_model|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Repair_type')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-repair_type" class="form-control" name="row[repair_type]" type="text" value="{$row.repair_type|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Title')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-title" class="form-control" name="row[title]" type="text" value="{$row.title|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Description')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-description" class="form-control" name="row[description]" type="text" value="{$row.description|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Annex')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-annex" class="form-control " rows="5" name="row[annex]" cols="50">{$row.annex|htmlentities}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Callout_fee')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-callout_fee" class="form-control" step="0.01" name="row[callout_fee]" type="number" value="{$row.callout_fee|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Inspection_fee')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-inspection_fee" class="form-control" step="0.01" name="row[inspection_fee]" type="number" value="{$row.inspection_fee|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Is_invoicing')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-is_invoicing" class="form-control" name="row[is_invoicing]" type="number" value="{$row.is_invoicing|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Invoicing_fee')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-invoicing_fee" class="form-control" step="0.01" name="row[invoicing_fee]" type="number" value="{$row.invoicing_fee|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Used_score')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-used_score" class="form-control" name="row[used_score]" type="number" value="{$row.used_score|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Score_money')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-score_money" class="form-control" step="0.01" name="row[score_money]" type="number" value="{$row.score_money|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('User_coupon_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-user_coupon_id" data-rule="required" data-source="user/coupon/index" class="form-control selectpage" name="row[user_coupon_id]" type="text" value="{$row.user_coupon_id|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Coupon_money')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-coupon_money" class="form-control" step="0.01" name="row[coupon_money]" type="number" value="{$row.coupon_money|htmlentities}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>
